The health care debate continues to be shot through with ideology and hyperbole as it has been for many years. Notwithstanding the florid rhetoric the starting point for any meaningful discussion has to be that we can no longer afford to maintain this country's health care system, which is by far the most expensive and least effective in the industrial world. Both of these deficiencies can and should be corrected.

Health care spending, about a quarter of which is Medicare (that's the government folks), has been growing more than twice as fast as the economy and now accounts for 20 percent of it ($2.8 trillion). If we are to pursue fiscal responsibility, cost control in this vital sector is an obvious necessity. Almost all informed observers (lately including the state of Vermont) agree that some sort of single-payer system (public or private) is the least costly. However, many of our citizens seem to feel that limiting choice in this fashion would be "un-American" and would intensify what they view as creeping socialism. These people should take a look at Germany, where a private system served by dozens of insurers delivers much higher quality at about half the per capita cost. Just a hint; German insurance and pharmaceutical companies neither make giant profits nor control the system.

The health care reform that is being implemented here stressed coverage before cost control as its primary purpose. Unfortunately, it doesn't cover everyone, and what savings it purports to offer are largely illusory. Some of its features are admirable (e.g., coverage despite previous conditions and coverage for offspring under their parents' policy until age 23), but we simply cannot afford it as constituted. Serious cost cutting is a given for the future United States health care.

In order to have useful discussions on this topic we need to discard terms that serve no purpose other than to inflame. One of these is rationing. Every health care system in the world rations. So does ours. As we realign we will have to talk about where we will ration and why. This interchange will be more important as we move out of necessity from a system that pays by procedure toward capitation that stresses preventive medicine.

More than 10 percent of our health care expenditures occurs in the last year of life, and the percentage is rising. Demonizing dialog about death panels that will pull the plug on grandma is decidedly unhelpful.Talking and strategizing about end of life situations will be crucial to any true reform.

The mandate that requires individuals to sign up for health care programs or pay a fine has raised the hackles in many quarters that value individual choice as the "American Way." There are valid economic reasons why every advanced country makes their citizens enroll in a proffered health care system. But if we really can't stomach this feature reasonable give and take can produce alternatives that, while perhaps not as good, can still be effective.

There is no way around it. We are going to have to cut health care spending, not merely slow its growth rate. A 10 percent annual reduction would be a good place to start. It would provide a saving of about $3 trillion in the course of a decade. The sooner we begin the process the better, and maybe we could see to it that all government employees, including elected ones, were put on the same type of plan as the rest of us.